00:00 – Dr. Kumar: I’ve seen in patients with recurrent urinary tract infections, someone who’s
00:04 – had chronic infections, we often see something called cystitis cystica, which is
00:08 – the bladder’s response to the chronic inflammation.
00:25 – Melissa: You just mentioned cystoscopy, maybe you can give us a bit more insight into what that is and what you use it to look for sure?
00:33 – Dr. Kumar: Cystoscopy is when we we take a look inside the bladder
00:38 – to evaluate the lining. I’ve seen in patients with recurrent urinary tract infections,
00:45 – someone who’s had chronic infections, we often see something called cystitis cystica,
00:50 – which is the the bladder’s response to the chronic inflammation. And it’s where you get
00:57 – the cells just sort of heaping up on top of each other and forming almost these like
01:02 – little tiny like nodules and sometimes you’ll see that diffusely. And
01:07 – I’ve had some patients actually where I’ve seen that and we’ve done a low-dose
01:13 – nitrofurantoin, like a daily nitrofurantoin to prevent UTIs for six months, and then I re-scope
01:20 – them and and it clears. And it’s pretty amazing. And then I’ve also seen where we’ve
01:28 – found a discrete area of inflammation and the tissue looks very ragged and has almost
01:35 – formed like a plaque, and I actually had a patient where I biopsied the tissue and
01:40 – I actually demonstrated the growth of bacteria in the tissue. I think that our ability to
01:48 – demonstrate the areas, like if we think that embedded UTI is a possibility, our ability
01:54 – to demonstrate that cystoscopically would be wonderful. And the
02:04 – other thing, obviously you always want to look for, especially if you have a patient who has
02:08 – irritative bladder symptoms and it’s ongoing, and they’re not responding to antibiotics, I think you
02:13 – you have to do a cystoscopy. You have to make sure there’s no cancer in the bladder and sometimes you
02:18 – may even find like endometriosis on the inside of the bladder. It’s pretty rare but
02:25 – that has certainly been found as well. And people can have other, like if
02:31 – you do a bladder biopsy, people can have findings like an increased concentration of eosinophils,
02:37 – which could be their symptoms are from increased mast cell activation in the bladder as
02:44 – opposed to UTI. So I have a low threshold to do cystoscopy. I think it’s important
02:50 – in the evaluation of somebody who’s having chronic, painful symptoms from their bladder.
02:54 – Melissa: Are there any side effects that could come from having a cystoscopy done?
03:00 – Dr. Kumar: I think it’s actually a very safe procedure.
03:04 – Here when we do it we use a very strong numbing jelly in the urethra. I often
03:09 – will dilate the urethra a little bit very gently so that when the scope goes in it’s not traumatic.
03:14 – So most my patients don’t complain of pain during or after, but certainly I know,
03:20 – I’ve had a lot of patients who’ve seen other urologists and they’ve been
03:24 – really traumatized by the cysto experience, because they’ve just sort of been laying there
03:29 – and then someone comes in the room and just puts a scope in and it’s very startling and
03:33 – painful. So I think it just has to be done right. It’s a very safe procedure.
03:39 – The risk of getting a UTI from the cystoscopy is about one to two percent.
03:46 – In our office we are very meticulous about sterile technique and
03:52 – numbing and things like that. So I don’t routinely give patients antibiotics for cystoscopy. So
03:58 – there’s a small risk for urinary tract infection, there’s a risk for irritative symptoms
04:03 – afterwards from the instrumentation which is usually temporary. So I find that
04:10 – the benefits of doing a cystoscopy certainly outweigh the risks.
04:13 – Melissa: In what percentage of patients do you actually find something on cystoscopy that you couldn’t have found otherwise?
04:20 – Dr. Kumar: That’s an interesting question. I would say in about 60 to 70 percent of patients.
04:27 – Occasionally I have a patient who’s having irritative symptoms and we look in the bladder and
04:34 – I’m like wow, I don’t see a single thing here that I would biopsy, that I would cauterize.
04:39 – It looks pristine. Most people will have a little inflammation at the trigone or
04:45 – something that we call squamous metaplasia, or they’ll have some area where you can tell
04:51 – they’ve had a UTI and there’s some inflammation of the tissue.
04:59 – I think if you find anything on cystoscopy, again it’s very low risk, so even if there’s
05:06 – a small chance that cauterizing it or taking a biopsy could help with diagnosis
05:12 – or treatment, I have a very low threshold to do that. And it’s interesting
05:19 – because when I have found there’s absolutely nothing in the bladder,
05:26 – and the urines are coming back negative, no white cells, no red cells,
05:33 – no signs of inflammation visibly, there are no signs of inflammation in that patient,
05:39 – I’m more prone to believe that their symptoms are from genitourinary syndrome of menopause.
05:44 – And we need to really focus our treatment on that.
05:47 – Melissa: Someone asked a question about bladder trabeculation. Can you explain what that is and if it is something that needs to be treated?
05:56 – Dr. Kumar: Yes, I can explain what it is. Bladder trabeculation is when there is a thickening
06:03 – of the muscle fibers in the bladder wall, and we usually see it in men. We often see it when the
06:10 – prostate is obstructing and creating an outflow obstruction so that the bladder muscle actually
06:16 – has to work harder to get urine out. In women, we actually tend to see it in women with overactive
06:23 – bladder. And so on the cystoscopy you’ll see where it looks like there are these
06:28 – sort of bands underneath the mucosa and those bands are just actually areas where the muscular
06:35 – layer of the bladder, where some muscle fibers are just thickened. And in women it correlates more with overactive bladder.
06:45 – Melissa: Is it a problem or is it just something that naturally happens in those cases?
06:48 – Dr. Kumar: I wouldn’t say it’s a problem. Sometimes you’ll see someone who has a
06:54 – severe degree of bladder dysfunction where their bladder is very trabeculated and there are also
07:00 – something called cellulase, where the muscle fibers are so thick that the mucosa sort of
07:04 – pooches out in between the thickened muscle fibers. So sometimes you’ll see that in patients who
07:10 – have a very bad, like neurogenic bladder, if they’ve had like a spinal cord injury, or you’ll see it in
07:16 – patients with very bad diabetes. So sometimes it can be a manifestation of a disease which
07:22 – is neurologically affecting the bladder but in most patients it’s mild and there’s nothing,
07:28 – aside from treating overactive bladder or treating bladder outlet obstruction,
07:34 – you don’t actually do anything about that finding. There’s nothing that you would do to those muscle fibers.
07:43 – Melissa: One thing that has come up a lot more in the last six months, and that we’ve
07:45 – been getting questions about is fulguration, and I know you’ve mentioned it before as well.
07:50 – So I was hoping that you could give us a bit of insight into what that is and how it might be used?
07:56 – Dr. Kumar: Sure. So typically when we do a cystoscopy, when we look inside the bladder,
08:03 – we’re taking a look around to make sure we don’t see any tumors or stones in the
08:08 – bladder, we like to see that the area where the urine flows in from the kidneys, that we see nice
08:15 – brisk clear flow of urine into that area. And often in women who have had urinary tract infections
08:25 – we can see areas where the bladder tissue has reacted to the inflammation and so you sometimes
08:33 – see these small sort of raised nodules and they don’t look at all like bladder cancer.
08:39 – But you can tell that the bladder has been reacting to some process and
08:45 – it’s felt that the bacteria, especially when we talk about embedded bacteria,
08:52 – that these areas, these nodules may be areas where the bacteria can reside. And so when you
09:00 – go in the bladder, doing a cystoscopy in the office, it’s not a procedure that’s typically
09:05 – done under anesthesia, it’s an office procedure where you come in,
09:10 – go home 15 minutes later. You can use a very small instrument if you see these
09:16 – tiny nodules, to actually cauterize them, which means you’re essentially gently burning them.
09:22 – So if you think about if you’ve ever had a skin tag or something on your face,
09:27 – where there’s something called a hyfrecator where your dermatologist
09:31 – might zap it off, they basically apply this electrical energy and it just sort of burns the
09:37 – tissue, and then it sloughs away. So fulguration is basically the same thing where we’re essentially
09:44 – very gently, we’re doing like a mechanical sort of cleaning of that tissue.
09:51 – And Philippe Zimmern out of UT Southwestern, has done studies showing that while
09:58 – it doesn’t help in 100 percent of recurrent UTI patients, in about 50 to 60 percent
10:06 – where they’ve cleared these small nodules, those women have had less urinary tract infections.
10:13 – And then in the women in whom it wasn’t necessarily successful, when they went back and
10:18 – did it a second or third time, there was some additional benefit. So I think again,
10:24 – when we do that it’s a very harmless, risk-free thing to do. There’s not a lot of risk in gently
10:31 – cauterizing these lesions. It’s similar to, like I said, if you had a skin lesion that was
10:37 – zapped or people who when they develop warts you get the freezing spray
10:44 – sprayed on the warts and then the tissue sloughs away. So it’s very similar to doing that
10:50 – and it’s very easy to do when the patient is there for cystoscopy anyway. So you’re
10:57 – not necessarily performing an extra procedure, you’re there and so if you see that
11:03 – there may be some utility in cauterizing those areas, I’m someone who favors
11:12 – things that could be beneficial, that carry low risk.
11:17 – Melissa: Is that a painful thing for a patient?
11:19 – Dr. Kumar: It feels, so sometimes what we do is we actually put lidocaine in the bladder for 30 minutes prior, which really helps to numb the bladder.
11:29 – And in that case you know you don’t really feel it. Without the lidocaine it feels like a little bit of a zapping sensation.
11:38 – But because it’s really at the surface mucosa, most patients, even if they feel it, even
11:46 – if they feel something, it’s tolerable. If you have a patient where you do one or two
11:52 – and it’s really painful for them then you might say let’s do this under anesthesia.
11:56 – And that’s also the benefit of having the patient awake so they can tell you, look,
12:00 – stop, I can’t tolerate this. Or they can say, yeah it’s fine, keep going.
12:07 – Melissa: One of the concerns that has been raised around this technique is the possibility that scar
12:11 – tissue will develop which can’t be a good thing in the bladder, I assume. Do you think the risk of
12:16 – that is low or do you think that risk is more in techniques where they’re fulgurating whole areas of the bladder?
12:23 – Dr. Kumar: I think that that risk is high when you are resecting deeper pieces
12:28 – of tissue in the bladder and if you’re doing it in multiple areas, like if you’re doing that
12:34 – diffusely throughout the bladder then you do have a greater risk of scarring and fibrosis.
12:41 – But I think with fulguration it’s so superficial that I don’t think
12:49 – you’re gonna end up with scarring of the underlying connective tissue. Now having said
12:54 – that, I mean some people have, in those studies he’s doing mostly at the trigone, which is
12:59 – the entry of the bladder, but some people do have diffuse, what we call cystitis cystica,
13:05 – and it’s all throughout the bladder. That’s very difficult
13:10 – to get to get every single one of those areas. And if you see that,
13:17 – to me that’s more a sign that the patient has really had chronic infection and that’s a
13:22 – patient who I’m actually more willing to put on a low-dose daily antibiotic like nitrofurantoin. I’ve
13:30 – seen that where we’ve done that for six months and I’ve looked back in and it’s actually,
13:34 – getting them UTI free for that good period of time, has allowed their bladder to heal.
13:41 – And you actually see resolution of the large majority of those lesions. But if it’s a discrete
13:47 – area and particularly the trigone, which is the entry area of the bladder,
13:54 – and you’re doing a superficial fulguration, then I don’t feel scarring is a major concern.
14:01 – And I think maybe we’re embracing strategies that are non-antibiotic, strategies that can
14:07 – potentially be helpful and again, I think there’s very little downside to trying it.